week two Flashcards by tia meechan

Describe the difference between LSIL and HSIL of the vulva and VIN

VIN: vulvar intraepithelial neoplasia

TYPES OF VIN:

LSIL: low grade squamous intraepithelial lesion of the vulva
Aka vulvar LSIL, flat condyloma, HPV effect
associated with HPV 6 and 11

HSIL: high grade squamous intraepithelial lesion of the vulva
VIN usual type, multifactorial
associated with HPV 16, 18, 31

How well did you know this?

Not at all

Perfectly

Which type of VIN is not associated with HPV and what is it associated with

dVIN (VIN differentiated type): lesions not associated with HPV but with vulvar dermatoses, mainly lichen sclerosus

How well did you know this?

Not at all

Perfectly

List common DDX’s for white, red or brown lesions of the vulva.

White (hypopigmented): lichen sclerosus, squamous hyperplasia, VIN, vitiligo

Red lesions (erythematous): vestibulodynia, vulvar candidiasis, lichen planus, VIN

Brown lesions (hyperpigmented): VIN, nevi, acanthosis nigricans

How well did you know this?

Not at all

Perfectly

What is the most common diagnostic work-up (test) of vulvar lesions?

biopsy; punch biopsy most common

How well did you know this?

Not at all

Perfectly

Describe the ways HPV affects the vulva (ddx)

How well did you know this?

Not at all

Perfectly

RF of VIN

Impaired immune response
Smoking
Early onset of sexual intercourse
Multiple sexual partners
Unprotected intercourse (mostly vaginal and cervical lesion risk) skin-to-skin contact
Uncircumcised partner(s)
Low socioeconomic status
Diet
HPV infection - about 90% of VIN lesions test pos for HPV
Differentiated VIN associated with lichen sclerosis

How well did you know this?

Not at all

Perfectly

Sx of VIN

Red, white, or brown lesions; usually flat + often asxs and noted incidentally during pelvic exam
Pruritus and pain or burning
Dysuria if periurethral VIN lesion or if urine comes in contact with a VIN lesion at another site
75% found in non-hair bearing areas, 30-40% multifocal, 15% on both non-hair bearing and hair bearing areas
Persistent abnormal cervical cytology with no abnormality identified on cervical biopsy - given SILs in this region are often multicentric, vulvar SIL can initially present with an abnormal cervical cytology result

How well did you know this?

Not at all

Perfectly

Natural oral treatment protocol for VIN

Methylated folic acid
Beta-carotene
Green tea extract (GTEx)
Berberine
Coriolus versicolor
Vit E
Vit C

How well did you know this?

Not at all

Perfectly

Pt applied tx VIN

Podofilox (Condylox)
Compounded cream - thuja EO, lomatium tincture vit A, vit E, green tea
Veregen (sinecatechins) ointment
Imiquimod 5% cream/aldara

How well did you know this?

Not at all

Perfectly

dr applied tx VIN

Cryotherapy
Trichloroacetic or bichloroacetic acid
Surgical removal

How well did you know this?

Not at all

Perfectly

What is the clinical presentation of vulvar cancer?

Often with vulvar lesion
Mostly asxs, can be pruritis or bleeding
Lesions unifocal vulvar plaque, ulcer, or mass (fleshy, nodular, warty) on labia majora, labia

How well did you know this?

Not at all

Perfectly

What are the signs and symptoms of lichen sclerosus

Pruritus (hallmark, often so severe it interferes with sleep)
Vulvar irritation
Burning
Dyspareunia
Testing, bleeding, fragility of vulvar skin
Discomfort due to involvement of perianal skin - pruritus ani, dyschezia and rectal bleeding, dysuria

White, atrophic papules that may coalesce into plaques
Labial agglutination
Pale parchment-like appearance of labia
White plaques
Labial atrophy
Narrowing of introitus
Phimosis or fusion over clitorus may cause diminished sexual sensation or even anorgasmia
May present with white plaques on other body surfaces (thighs, breasts, wrists, shoulders, neck, back, and rarely oral cavity)
Anatomical changes can lead to pain, sexual difficulties, and voiding problems

How well did you know this?

Not at all

Perfectly

dx lichen sclerosis

BIOPSY - reveals subepithelial fibrosis and four cardinal histological features

How well did you know this?

Not at all

Perfectly

what are the four features needed on biopsy for dx of lichen sclerosis

Atrophy of epidermis with disappearance of rete pegs
Hypertrophic degeneration of basal cells
Replacement of underlying dermis by dense collagenous fibrous tissue
A monoclonal band-like lymphocytic infiltrate

How well did you know this?

Not at all

Perfectly

What is the treatment necessary to decrease progression of disease and how is it prescribed?

How well did you know this?

Not at all

Perfectly

What naturopathic support can be used for tx of lichen sclerosus?

Anti-inflammatory diet
Eliminate gluten
Support TH3 pathway (Probiotics, Fish oil, Vit D)
Healthy hygiene habits

How well did you know this?

Not at all

Perfectly

What are some other benign dermatoses?

How well did you know this?

Not at all

Perfectly

What is necessary to diagnose vulvodynia?

Vulvar pain localized to the vulvar vestibule, with or without clitoris, of at least 3 months duration, without clear identifiable cause, pain elicited with pressure point testing, which may have potential associated factors

How well did you know this?

Not at all

Perfectly

List the signs and symptoms of vulvodynia

Vulvar pain - burning, irritating, sharp, prickly, pruritic with vaginal intercourse, tampon insertion, tight clothing, prolonged sitting, biking, or other spots
Pain can be immediate or delayed and discomfort can persist or resolve on its own
Pain is sufficiently severe to limit sexual function, cause psychological distress, impair relationships, and/or adversely affect routine activities
Often associated with other chronic pain conditions

How well did you know this?

Not at all

Perfectly

What test is commonly used during a physical exam of vulvodynia?

cotton swab test

How well did you know this?

Not at all

Perfectly

As vulvodynia is of multifactorial causes, list 1 or 2 treatments to address each cause.

Discontinue scented detergents, soaps, etc
Discontinue OCs
Eliminate tight clothing
Sitz baths
Lubricants without alcohol or warming agents -
Discontinue bikes, horseback riding
Cold sitz baths, ice packs to vulva
Castor oil packs to abdomen and vulva
Low oxalate diet, anti-inflammatory diet
Calcium citrate
Fish oils
Compound cream with vit A/E
Pelvic floor therapy
Superficial perineal massage
Vaginal dilators
Biofeedback
Hypnosis
CBT
Sex therapy, couple therapy
Pharmaceuticals
Topical tx - anesthetics, ELA cream gabapentin, amitriptyline, estrogne, cromolyn, vaginal prasterone, androgens
Oral meds (2nd tier): gabapentin, amitriptyline, cymbalta, lyrica, tricyclic antidepressants
Third tier - intralesional injection of steroids and bupivacaine, botulinum neurotoxin A
Surgery; perineoplasty and vestibuloplasty
Multi level nerve blockade

How well did you know this?

Not at all

Perfectly

ASC-US

atypical squamous cells of undetermined significance

How well did you know this?

Not at all

Perfectly

ASC-H

atypical squamous cells cannot r/o high-grade lesion

How well did you know this?

Not at all

Perfectly

CIN1

LSIL, mild dysplasia (historial)

How well did you know this?

Not at all

Perfectly

CIN2

HSIL, moderate dysplasia (historical)

CIN3

HSIL, severe dysplasia or carcinoma in situ (CIS) (historical)

AGC

atypical glandular cells

VaIN vs VIN

VAginal va Vulvar intraepithelial neoplasia

What is the cause of virtually all cervical cancer?

HPV infxn

what are the two main types of cervical cancer and the main HPV type causing each?

SCC (93%) - HPV 16 Adenocarcinoma - HPV 18

How is HPV transmitted and what 2 strains are the most oncogenic or virulent?

Genital HPV is transmitted by skin to skin contact via vaginal or anal intercourse most commonly; nonpenetrative genital contact possible but rare 90% cancer cases are HPV 16/18; most virulent

list 4 risk factors that increase the risk of developing cervical cancer

smoking OCPs uncircumcised males chlamydia infxn

MOA smoking as a RF for cervical cancer

metabolites of nicotine concentrate in cervical tissue, increasing duratino of HPV infxn; lowers immune response

MOA OCPs as a RF for cervical cancer

estrogen inhibits oxidative stress induced apoptosis > dec DC ability to present Ag to be kills dec Th1, inc Th2

MOA chlamydia infxn as a RF for cervical cancer

inc expression HPV 16, inc growth factor and receptor expression

Write the key differences between the 2012 and new 2019 guidelines around HPV/cervical cancer testing

Change from primary test results-based algorithms to primary “risk-based” guidelines

List the factors that protect against HPV infection or prevention

Cervical cancer screening HPV vaccine Condoms Secondary prevention - monitoring

List the guidelines for use of HPV testing.

Start screening age 21 For women <25; cytology every 3 years For women >25: cytology every 3 years or HPV testing alone, co testing HPV and cytology every 5 years*, HPV testing alone every 5 years Stop screening 65-70 that meet criteria; no hx of CIN in last 25 years Discontinue surveillance with limited life expectancy

If HPV testing is used as primary screening what is recommended if the test is negative and what is recommended if the test is positive?

Negative: screening is recommended no sooner than 3 years Positive: reflex cytology regardless of genotyping if reflex testing is not feasible pt should have colposcopy and additional cytology test is recommended If positive and genotyped to 16/18 go to colposcopy

What age is cervical cancer screening to begin; when is it to be discontinues?

Begin: 21 Discontinued: at 65-70 yo for women with evidence of adequate negative prior screening (three consecutive negative cytology results or two consecutive negative co-tests within the previous 10 yrs, with the most recent test within the previous 5 yrs)

What are the guidelines for patients post hysterectomy for screening or management?

If surgery is for benign reasons and no previous diagnosis of CIN 2 within the previous 25 years or have completed the 25 year surveillance period If surgery is performed for treatment, pt should have 3 consecutive annual HPV-based tests before entering long-term surveillance (3 year HPV testing for 25 years)

When are endometrial cells on the pap considered abnormal?

Postmenopausal

What the sxs of cervical cancer?

Postmenopausal bleeding Metrorrhagia Postcoital bleeding Vaginal discharge Pain

When you refer a patient for colposcopy what do you tell her to expect? What do providers do when they perform colposcopy?

Visualize the external genitalia, vagina, cervix after application of acetic acid or lugol's (iodine) to identify lesions/vascular abnormalities Determine if the colposcopy is satisfactory or adequate: able to visualize the entire SCJ & all of the borders of the lesions Biopsy the all abnormal lesions on exocervix (2-4 biopsies recommended). Perform an endocervical curettage. (ECC) unless C/I. Analyze the histopathology & pap/HPV results in combination with the colposcopy findings to determine the treatment & management plan for the patient.

When HSIL is diagnosed, when is immediate tx recommended/preferred and when is observation acceptable and unacceptable?

What is the suggested guideline for surveillance for HSIL in pats ≥ 25 yo and younger than 25 yo?

<25 observation > 25 colposcopy at 6 and 12 month and diagnostic excisional procedure

List excisional treatment options and ablative treatment options for VIN and when it is acceptable to use ablative procedures.

Excisional: cold knife, LEEP and laser Ablation: cryotherapy, laser ablation, and escharotic treatment used with colposcopy is adequate and the lesion covers less than 75% of the surface area of the ectocervix

List the obstetrical complications associated with excisional procedures.

Cervical stenosis Premature rupture of membranes Preterm delivery

List the components of escharotic treatment and when it is an option for a patient

Bromelain Calendula officinalis ZnCl Vag Pack Suppositories Indications Used in cases of CIN 2, 3 with an adequate colposcopy, ECC, in some cases of persistent CIN 1

List the common nutrients and botanicals with doses given orally for HPV related disease process.

Vitamin E Folic Acid Vitamin C DIM (diindolylmethane) Green tea extracts (GTE) Berberine Coriolus Versicolor

Which vaccine is available in the US for HPV and what strains does it cover; what genders and ages is it acceptable to be given.

Gardasil 9: 6, 11, 16, 18, 31, 33, 45, 52, and 58 Females: 11-12, catch-up recommended for females aged 13 to 26 years who have not completed the vaccine series Males: 11-12, catch-up recommended for males aged 13 to 21 and 22 to 26 years old if they are men who have sex with men or immunocompromised Individuals initiating the vaccine series before 15 years of age – Two doses at 0 and at 6 to 12 months. Individuals initiating the vaccine series at 15 years of age or older – Three doses of HPV vaccine should be given at 0, 1 to 2 (typically 2), and 6 months.

What is the pH of the vagina? 3.5-4.5 3-4 5-6 6-7

3.5-4.5

What does lactobacillus produce? Lactic acid H2O2 H2O Lactic Acid + H2O2

Lactic Acid + H2O2

Which of the following does not impact the vaginal ecosystem? Menstruation Tampons Seamen Water

Water

What is vaginosis? Infection of vaginal canal Inflammation of vaginal canal Milky white vaginal discharge Vaginal bleeding

Infection of vaginal canal

What are hypoestrogenic states? Postpartum Lactation Genitourinary syndrome of menopause POI All of the above

All of the above

What are the effects of low estrogen on the body? Decreased maturation of vaginal epithelium Vagina shortens Loss of rugae Pale in color All of the above

All of the above

Which cells of the vgainal epithelium grow when there is no/low estrogen? Superficial Intermediate Parabasal Basal

Parabasal

Which of the following is false in regards to GSM sx Dyspareunia Pruritus Bleeding Cramping

Cramping

Which of the following is TRUE in regards to the GSM pelvic exam? Labia minora enlargement Urethral meatus decreases in prominence Tissue fragility Increase in secretions/lubrication

Tissue fragility

How is GSM diagnosed? Clinically Diagnosis of exclusion Imaging Labs

Clinically

What is the first line treatment for GSM Nonhormonal moisturizers and lubricants Hormonal/estrogen creams Hyaluronic acid Oral estrogen

Nonhormonal moisturizers and lubricants

What are common causes of irritant vaginitis Latex Spermicides Soaps All of the above

All of the above

What are the 3 most common vaginitis? Candida, Chlamydia, Gonorrhea Candida, trichomoniasis, syphilis Candida, trichomoniasis, bacterial Candida, trichomoniasis, chlamydia

Candida, trichomoniasis, bacterial

What is the discharge associated with Candida vaginitis? Green Yellow White Gray

White

What is the pH associated with Candida vaginitis? 4.5 5 7 2

Which infection(s) has a positive whiff test/ KOH test? Candida Trichomoniasis Bacterial Two of the above

Two of above; trich and bacterial

What are the findings on a wet mount that suggest candida infection? Pseudohyphae Motile trichomonads Clue cells Broad waxy casts

Pseudohyphae

What is the color of the discharge associated with trichomoniasis infection? Green/yellow Gray White Red

Green/yellow

What is the pH associated with trichomonas infection? 4.5 5 7 2

What are the findings on a wet mount that suggests trichomonas infection? Pseudohyphae Motile trichomonads Clue cells Broad waxy casts

Motile trichomonads

What is the color of the discharge associated with bacterial vaginosis? White Green Yellow gray/white

gray/white

What is the consistency of the discharge associated with bacterial vaginosis? Thick, clumpy, Frothy, thin Thin, watery None of the above

Thin, watery

What are the signs and symptoms associated with candida? Vulvar itching Dyspareunia Dysuria All of the above

All of the above

Which condition is associated with a fishy odor with vaginal discharge? Bacterial vaginosis Candida Trichomonas Chlamydia

BV (Trich can also have fishy odor d/c)

How is candida diagnosed? Normal pH Spores, hyphae, yeast bids on wet prep Addition of KOH removes debris that obscures hyphae All of the above

All of the above

What are complications associated with bacterial vaginosis? Preterm birth PID Endometritis All of the above

All of the above

What are the organisms associated with BV? Gardnerella Mycoplasma hominus Mobiluncus Ureaplasma urealyticum All of the above

All of the above

Which symptoms are not associated with BV? Pruritus Fishy odor Abnormal d/c

Pruritus

What is not included in the amsel criteria? Increased homogeneous thin vaginal discharge pH is greater than 4.5 Positive whiff test Absence of clue cells

Absence of clue cells

Which of the following is not a symptom of cytolytic vaginosis? Pruritus and burning Dyspareunia and dysuria Abnormal bleeding Slight to abundant severe whitish d/c

Abnormal bleeding

Which of these does not point towards diagnosing cytolytic vaginosis? Presence of d/c pH 3.5-4.5 Absence of other causes on wet prep Low amount of lactobacilli on culture

Low amount of lactobacilli on culture

What is the discharge of group B streptococcus? White, yellow, stretchy, copious Thick, curdly, white discharge Frothy, green/yellow Thin, white/gray

White, yellow, stretchy, copious

What are the results of the wet prep for Group B Strep? > 50 WBC Chains of cocci Hyphae A and B

> 50 WBC Chains of cocci

Desquamative Inflammatory Vaginitis etiology? Absence of lactobacilli Overgrowth of lactobacilli

Absence of lactobacilli

Which of the following is false of the symptoms of Desquamative Inflammatory Vaginitis? Pain Copious, yellow, green, or gray Pruritus None of the above

Pruritus

Which of the following wouldn’t you find on PE for DIV? Vestibule may be thinned, sensitive, erythematous or edematous Spotty ecchymotic rash Erosive lesions of cervix Pale external genitalia

Pale external genitalia

Which of the following is not a part of the diagnostic criteria for DIV? At least one of following: vaginal discharge, dyspareunia, pruritus, burning, irritation Spotted ecchymotic rash, erythema, focal or linear erosion pH < 4.5 Saline microscopy showering increased numbers of parabasal and inflammatory cells

pH < 4.5

What is not a way to prevent vaginitis generally? Whole food diet Probiotics Spandex garments Cotton undergarments

Spandex garments

Which of the following represents the discharge present in vaginal cancer? Watery, blood-tinged or malodorous Copious, yellow, green, or gray White, yellow, stretchy, copious Thick, curdly, white discharge

Watery, blood-tinged or malodorous

week two Flashcards

(91 cards)